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Based on observation, interview, medical record review, policy review and plumbing replacement document reviews the facility failed to provide care in a safe setting to 45of 55 current and two of two discharged Behavioral Health (BH) Service patients by failing to:
-Remove/replace plumbing fixtures in patient bathrooms that could be used by suicidal patients as ligature points or implement a plan to ensure patient safety;
-Ensure six of seven patient care technicians (PCTs) and patient care assistants (PCAs) who "float" to the BH units have appropriate orientation and training for specialized monitoring and care of BH patients. (Refer to A 0144).

The cumulative results of these findings resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation: Patient's Rights.

Based on interview, record review and policy review, the facility failed to ensure that the facility's written response to patient grievances included the date the grievance investigation was completed for 9 (#49, #50, #51, #52, #54, #55, #56, #57, and #58) of 10 patient grievances reviewed. The facility census was 553.

Findings included:

1. Record review of the facility's policy titled "Patient/Patient Representative Complaints/Grievances" revised on 09/13/11, showed that the written response to a grievance should include the date the grievance investigation was completed.

2. Record review of discharged Patient #49's grievance file included a follow-up letter dated 04/11/12. The letter was addressed to the patient and indicated the grievance investigation had been completed, but did not include the date the investigation was completed.

Record review of discharged Patient #50's grievance file included a follow-up letter dated 03/07/12. The letter was addressed to the patient representative and indicated the grievance investigation had been completed, but did not include the date the investigation was completed.

Record review of discharged Patient #51's grievance file indicated that a grievance filed by the patient's representative was resolved on 04/10/12. The grievance file included a follow-up letter addressed to the patient's representative, dated 04/07/12, three days before the grievance was received by the facility. The letter did not include the date the grievance investigation was completed.

Record review of discharged Patient #52's grievance file included a follow-up letter dated 05/03/12. The letter was addressed to the patient representative and indicated the grievance investigation had been completed, but did not include the date the investigation was completed.

Record review of discharged Patient #54's grievance file included a follow-up letter dated 02/17/12. The letter was addressed to the patient representative and indicated the grievance investigation had been completed, but did not include the date the investigation was completed.

Record review of discharged Patient #55's grievance file indicated that a grievance was filed by the patient on 03/21/12. The file included a follow-up letter dated 03/19/12, two days before the grievance was received by the facility. The letter did not include the date the grievance investigation was completed.

Record review of discharged Patient #56's grievance file indicated that a grievance filed by the patient was resolved on 04/10/12. The file included a follow-up letter dated 04/13/12. The letter was addressed to the patient and indicated the grievance investigation had been completed, but did not include the date the investigation was completed.

Record review of discharged Patient #57's grievance file included a follow-up letter dated 05/07/12. The letter was addressed to the patient and indicated the grievance investigation had been completed, but did not include the date the investigation was completed.

Record review of discharged Patient #58's grievance file included a follow-up letter dated 01/23/12. The letter was addressed to the patient and patient representative, and indicated the grievance investigation had been completed, but did not include the date the investigation was completed.

3. During an interview on 05/10/12 at 1:25 PM, Staff SS, Director of Patient Relations stated that the date in the date line (date above the addressee's name and address on a formal letter) of the grievance follow-up letters served as notification to the patient or patient representative of the investigation resolution (completion) date. Staff SS verified that the dates on the date line of the follow-up letter did not always reflect the completion date as recorded in the grievance investigation, as found during record review of Patient #51, #55 and #56's grievance file.

Based on observations, interviews, medical record reviews, policy reviews, plumbing replacement document reviews and recognized standards of practice, the facility failed to ensure the patients on suicidal precautions which were 45 of 55 current Behavioral Health Service Patients and two of two discharged suicidal patients were provided care in a safe setting in 34 of 34 patient bathrooms when the facility failed to provide an environment aimed at preventing looping and hanging. The facility also failed to ensure six (Staff TT, UU, VV, WW, XX, ZZ) of seven patient care technicians (PCTs) and assistants (PCAs) who "float" to the BH acute unit 5W had appropriate orientation and training for the specialized monitoring and care required by patients. This had the potential to affect all patients on the Behavioral Health Units with a census of 12 on BH acute unit 5W and 43 on BH Conley Unit.

The facility census was 553.

Findings included:

1. Recognized standards of practice for a psychiatric facility include:
The Veteran's Health Administration (VHA) National Center for Patient Safety formed a national committee that developed The Environment of Care Checklist for the purpose of reducing environmental factors that contribute to inpatient suicides, suicide attempts, and other self-injurious behaviors. This initiative is consistent with current literature on prevention of suicidal behaviors (Suicide Prevention Strategies: A systematic review. The Journal of the American Medical Association, (JAMA), 2005, v 294, 2064-2074).

JAMA, published continuously since 1883, is an international peer-reviewed general medical journal published 48 times per year. JAMA is the most widely circulated medical journal in the world.

The VHA and JAMA have all established accepted standards of practice for psychiatric inpatient facilities in the United States.
The VHA committee developed the Mental Health Environment of Care Checklist (MHEOCC) with the goal to prospectively identify and eliminate environmental risks for inpatient suicide and suicide attempts. The following are some of the items included on the MHEOCC to reduce environmental risks for inpatient suicide:
- Faucets and spouts in sinks and showers should be an institutional type. There should be handheld shower devices and no temperature adjusting devices within the showers (unless recessed). Shower heads should be institutional type. Institutional faucets will not provide an anchor point for hanging.

2. Record review of the facility's policy titled, "Safety Measures" last revised 07/11 showed the following:
- All patients are assessed on admission and every shift while hospitalized (nights while awake) by the assigned nurse to determine intent to harm self or others;
- An order for the appropriate level of precaution is obtained from the admitting psychiatrist or a nurse can initiate a necessary precaution and notify the physician.

Record review of the facility's policy titled, "Suicide Precautions: Intent to Harm Self or Others" last revised 04/10, stated the following:
- Precautions to address the patient's risk of self harm or harm towards others are to be initiated for any patient who is felt to be at risk due to having made a suicidal gesture, verbalized active suicidal thoughts, has a history of recent suicide attempts or a history of physical aggression towards others;
- CRITERIA FOR LEVELS OF PRECAUTIONS FOR INTENT TO HARM SELF OR OTHERS:
Level A: Patient who has actively verbalized plan to hurt him/herself or to hurt someone else. Patient has intent but without active plan or available means and access to the person in the case of harm to others.

Record review of the facility's daily census report dated 05/08/12 showed 45 current Patients (#13, #14, #15, #16, #17, #24, #25, #26, #38, #39, #45, #46, #47, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #92, #93, #94 and #95) of 55 patients and two discharged Patients (#1, #2) on the Behavior Health Units had been assessed as Suicide Level A (SLA.)

3. Observation on 05/08/12 at 2:30 PM showed private in-room patient bathrooms in the following rooms, numbered: 102, 103, 104, 105, 106; 125, 126, 127, 128, 129; 2207, 2209, 2210, 2211; 2220, 2221, 2222, 2224; 2232, 2233, 2234, 2235, 2236, 2237, 2238; 2240, 2241, 2243, 2244; 5101, 5102, 5105, 5106, and 5107) with stationary shower knob controls protruding three inches from the wall and varying in height from 41 inches to 51 inches from the floor. The lavatory faucet handles were ridged and pointed on the ends on either side of the stationary faucet. These bathroom fixtures provided a potential looping mechanism for the purpose of hanging.

During an interview on 05/08/12 at 3:00 PM, Staff B, Executive Director of the Behavioral Health Department, stated, "We identified the bathroom faucets as a safety hazard on our last rounds". Staff B explained that she and Staff MM, Vice President of Safety and Security, had performed unit rounds on the Behavior Health Units monthly for the last four to five months to look for possible safety issues. Staff B stated that all bathrooms on the Behavior Health Units are equipped exactly the same.

Observations on the afternoon of 05/08/12 and the morning and afternoon of 05/09/12 showed patients' doors are unlocked at all times and patients were observed going in and out of rooms at will and to use the bathrooms.

4. Review of a printed interdepartmental email (electronic mail) dated 03/19/12, sent by Staff O, Operations Assistant, directed to Staff B showed the following:
- Coordinate installation of anti ligature shower knobs in patients' room, also needs to look at faucets in all patients bathrooms.
Staff O had completed the Behavior Unit rounding with Staff MM for the month of March and this email was sent to Staff B for current updates of safety issues and provides information that the facility was aware of the bathroom safety hazards in March 2012 and failed to make the changes as directed.

5. During an interview on 05/09/12 at 12:30 PM, Staff LL, Director of Accreditation and Licensure Quality, stated that Risk Management is working on a plan to keep the patients safe in reference to the shower controls and faucets. He stated there was no current plan in place because, "We felt we already had enough things in place that we didn't need to do anything else".

During an interview on 05/09/12 at 1:55 PM, Staff B stated that no additional safety plan had been put in place because they weren't sure they were staying in that building and had been discussing options and costs for changes. Staff B stated they felt they were taking steps [for patient safety], like heightened awareness and 15-minute rounding education, but didn't have any formal written plan.

During an interview on 05/09/12 at 10:35 AM, Patient #25 stated that she was 18 years old and had been admitted to the child/adolescent unit because he/she had suicidal thoughts.

During an interview on 05/09/12 at 3:10 PM, Staff KK, Registered Nurse, stated that she has a current patient (#73) on her unit that was at risk for attempting suicide by hanging. Staff KK stated that about five percent of the patients are suicidal. She stated she found a patient a few years ago that committed suicide on her unit by hanging.

6. Record review of discharged Patient #63 showed that on 02/06/12 the patient was found standing in front of the mirror in the bathroom with a pillow case tied to a towel, twisted to emulate a rope, wrapped around her neck.

During a telephone interview on 05/10/12 at 9:14 AM, Staff MM, Vice President of Safety and Security stated it was his responsibility to present to the budget committee a plan to replace the bathroom fixtures on the Behavior Health Units. He stated that he first became aware of the shower control issue last fall 2011 and began getting supplier quotes for replacement of the bathroom shower controls. Staff MM provided a price quote dated 01/03/11 that showed a quote for 40 anti-ligature pressure balancing shower valves with handles. He stated that the shower heads had not been ordered or installed because there was confusion as to which fixtures should be ordered and there were other priorities [in the facility budget] ahead of them.

7. Record review of the facility's Behavioral Health Orientation Manual dated 01/17/12 showed the following topics were discussed during orientation:
-The Essence of Patient Care which included a topic titled "Every Patient Encounter is an Opportunity to Make a Difference".
-Communication was a two way process that related to verbal interactions and non-verbal interaction (interpretation and observational skills - looking and seeing).
-Non-verbal communication involved staff being aware of non-verbal messages that show how a person was feeling or how a person may respond.

Record review of discharged Patient #1's admission history and physical dated 04/03/12 showed the psychiatrist assessed the patient had a long history of abuse as a child and hospital admissions for history of multiple suicide attempts and swallowing foreign objects.

Further record review of Patient #1's admission history and physical dated 04/03/12 showed the psychiatrist assessed the patient with auditory hallucinations; suicidal ideation with a current plan to swallow foreign objects; poor memory and concentration; limited judgment and insight; and borderline intellectual functioning.

Record review of discharged Patient #2's admission history and physical showed the patient was admitted to the BH unit on 04/13/12 because he was hearing voices telling him to commit suicide and the psychiatrist assessed the patient was malingering and wanted to be admitted for a place to stay overnight.

Record review of Patient #1's nurses notes dated 04/13/12 showed Patient #1 was found in a bathroom, seated on a toilet with underwear around her thighs with a male patient (Patient #2) fully clothed standing in front of her. Further review showed Patient #1 wrote an account of the incident and described it as vaginal, anal and oral non-consensual sex.

During an interview on 05/09/12 from 7:25 AM through 7:55 AM Staff G, Patient Care Technician (PCT) stated the following:
-She had been in the "float" pool (staff who could be assigned anywhere in the facility) for about three and a half years.
-She was sometimes assigned to work in the BH.
-She had been assigned to monitor patients in the Day/Activity room.
-During the evening of 04/13/12, Patient #1 and Patient #2 were seated at a table in the Day/Activity room talking.
-Staff G did not recall any conversation, gestures or signals between Patient #1 and Patient #2 that seemed out of the ordinary (they were just talking).
-She had Crisis Prevention Institute (CPI) training (training in management of assaultive or disruptive behaviors).
-She had not had any other specialized training on how to provide care and monitoring on the BH unit.
-She is scheduled for BH unit orientation training in 06/12.

Record review of Staff G's personnel file showed she had not had BH unit orientation.

Record review of the facility's list of PCTs showed the following:
-Eight PCTs were listed as members of the "float" pool.
-Of the eight, seven had not had CPI training (planned for 08/12, 09/12 and 12/12).
-Of the eight, one had BH orientation, one was identified as not needing BH orientation because of previously being a staff member on a BH unit and six had no BH orientation training.

During an interview on 05/10/12 at approximately 1:50 PM, Staff PP, Director of Human Resources confirmed the following:
-Staff G had not been provided BH orientation.
-Most of the PCT float pool (six of seven, Staff TT, UU, VV, WW, XX, ZZ) had not had BH orientation.
-The lack of basic BH orientation for the PCTs was identified as an opportunity to improve.













27029

Based on interview, record review and policy review, the facility failed to notify The Centers for Medicare & Medicaid (CMS) by telephone to report patient deaths for four (#59, #60, #61, #62) of four records reviewed for patient deaths that occurred while in restraints. The facility census was 553.

Findings included:

1. Record review of the facility's policy titled "Reporting Patient Deaths Related to Restraint or Seclusion" revised on 07/11, did not indicate a process to report patient deaths in restraints to CMS by telephone.

2. Record review of Patient #59's Death Report Worksheet indicated that the patient died on 05/05/12 while in restraints. A fax confirmation indicated that the worksheet was faxed to CMS on 05/07/12, but did not indicate that the death in restraint was reported to CMS by telephone.

Record review of Patient #60's Death Report Worksheet indicated that the patient died on 01/14/12 while in restraints. A fax confirmation indicated that the worksheet was faxed to CMS on 01/16/12, but did not indicate that the death in restraint was reported to CMS by telephone.

Record review of Patient #61's Death Report Worksheet indicated that the patient died on 01/14/12 while in restraints. A fax confirmation indicated that the worksheet was faxed to CMS on 01/16/12, but did not indicate that the death in restraint was reported to CMS by telephone.

Record review of Patient #62's Death Report Worksheet indicated that the patient died on 01/14/12 while in restraints. A fax confirmation indicated that the worksheet was faxed to CMS on 01/16/12, but did not indicate that the death in restraint was reported to CMS by telephone.

3. During an interview on 05/10/12 at 2:25 PM, Staff RR, Patient Safety Manager stated that the facility notified CMS of patient deaths in restraints by fax, but did not notify CMS by telephone.